Every finding on record at Sun Spruce Healthcare LLC

A recertification survey was completed on 2/11/26. There were two deficiencies cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to conduct and document a risk assessment for the geographical location of appropriate hazards or potential emergencies related to the home care agency. Findings include: 1. Record review revealed that the agency did not appropriately identify all hazards, or potential emergencies. Risk assessment showed that volcano and tsunami/tidal wave was ranked high for preparedness. Record review showed the agency had a policy for emergency preparedness, however it did not include how the agency would conduct an assessment of all high hazards or potential emergency situation the agency could encounter in order to develop an emergency preparedness plan that addressed each hazard or potential emergency situation. During an interview on 2/11/26 at 11:02 a.m., the executive director stated she made a mistake when making the risk assessment and that volcano and tsunami/tidal wave should not be on the risk assessment. She also stated that she has not looked at the risk assessment nor the emergency preparedness plan thoroughly in over a year and a half.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff followed the plan of care only as ordered by the physician for 1 of 1 consumers receiving home health aid (HHA) services (Patient #3) and 2 of 4 patients receiving wound care (Patient #5 and #10). 1. The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification period dated 1/10/26 to 3/10/26 revealed a start of care date of 5/15/25; diagnoses included multiple sclerosis, bed confinement, urinary catheter, peg tube, and tracheostomy. The plan of care stated HHA visits three times weekly for eight weeks.. HHA services on the plan of care dated 1/10/26 include taking vital signs, turn and position in bed, transfer patient, bathing, hair care, skin, care, routine catheter care, perineal care, sharing, oral care, nail care, fall precautions, ostomy care, reporting any changes in skin condition. a) Record review and interview showed the agency failed to ensure the HHA services was provided as ordered by the physician for Patient #3. During a home visit on 2/10/26 at 11:00 a.m., the patients medical durable power of attorney (MDPOA) stated that HHA #8 provided homemaking services such as bathroom cleaning, laundry, tidying common living spaces, and vacuuming. The MDPOA stated that the HHA also helped remind the consumer and herself to take medications. During a home visit at 11:00 a.m., HHA #8 stated that she provided homemaking services and medication reminders. During an interview on 2/10/26 at 3:09 p.m. with the executive director and the administrator, they stated that it was an oversight that the homemaking tasks and medication reminder was not on the aid care plan. They stated that the agency was going to do clinician training on how to do a complete plan of care. 2. The clinical record for Patient #5 was reviewed on 2/10/26. The plan of care for the certification period dated 12/24/25 to 2/21/26 revealed a start of care date of 1/4/24; diagnoses included chronic venous hypertension with ulcer and ulcer on right calf. Plan of care orders included skilled nurse (SN) visits two times weekly unless the patient goes to the wound care clinic that week then one visit weekly for assessment, education, and management of wound care. a) Observations showed the agency failed to ensure wound care was provided only as ordered by the physician for Patient #5. During record review on 2/10/26 on Patient #5’s nursing visit note on 12/26/25, licensed practical nurse (LPN) #5 stated that she cleansed with no rinse foam soap, rinsed twice, applied vaseline from foot to knee, applied calcium alginate AG, covered with stretch unna boot, rolled gauze, and applied self absorbent wrap. At the beginning of the nursing note sectioned “wound care provided” the LPN documented “this order has not yet been approved”. Similar findings for all of the nursing notes documented during the certification period until 2/9/26. When reviewing physician orders there were none within the record. A home visit was conducted on 2/10/26 at 9:30 a.m. for Patient #5. The surveyor observed LPN #5 providing wound care to Patient #5's right lower extremity wound. A paper barrier was placed on the floor and then Patient #5 right lower extremity was placed on top of the barrier. LPN #4 then cleansed with no rinse foam soap, rinsed twice, applied vaseline from foot to knee, applied calcium alginate AG, covered with stretch unna boot, rolled gauze, and applied self absorbent wrap. During an interview on 2/10/26 at 3:25 p.m., the administrator stated that they did not have the physician orders within the record and she was unsure of where the direction of how to clean the wound came from. She stated that in the coordination notes, LPN #5 called and left a voicemail for the physician office to get verbal confirmation on wound care orders. The administrator stated that the agency wiould obtain verbal orders for wound care for Patient #5 that day. 3. Review of Patient #10 with certification dated 12/17/25 to 2/14/26 revealed a physician order dated 1/7/26 had the following wound care orders: cleanse right buttock, I&D with vashe, pat dry, apply stoma pate to gluteal cleft and any other creases around periwound.surrounding tissue, then skin prep, vac drape, apply moderate amount of santyl ung to wound bed and cavity, pack cavity with black foam, bridge to left lower back, apply trac pad and vac drape to secure, negative pressure wound therapy to -125 MMHG continuous. On 1/20/26 physician order changed the negative wound therapy pressure to -150 MM continuous. a) The agency failed to ensure wound care was provided only as ordered by the physician. These orders were to be followed for the wound on Patient #10's right buttock twice a week for one week and once a week for two weeks. Record review of the nursing note dated 2/9/26 by registered nurse (RN) #6 documented under wound care provided, they continued previous orders except pack cavity with white foam, black foam overlay to rest of wound. Increased pressure to -150 MMHG, continuous. On 2/6/26 and 1/28/26 the RN documented the same statement under wound care provided. During an interview on 2/10/26 at 3:48 p.m., the administrator stated that the RN did not document the wound care properly and should have listed out every step that they provided. She stated that the standard was not to copy and paste orders from previous visits. She stated that they would begin doing chart audits to make sure that tasks are being fully documented as physician ordered.

A complaint survey, prompted by #CO101869 was completed on 11/16/23. One deficiency was cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure services and treatments were provided in accordance with physician's orders for 3 of 5 patients reviewed (Patient #1, #3 and #4). Findings include: 1. The clinical record for Patient #3 was reviewed on 11/16/23. The Plan of Care for the certification period dated 8/24/23 to 10/22/23 revealed a start of care date of 8/24/23; diagnosis included encounter for change or removal of nonsurgical wound dressing, type two diabetes with diabetic peripheral angiopathy without gangrene, venous insufficiency, non pressure chronic ulcer of right calf with fat layer exposed and non pressure chronic ulcer of right lower leg with fat layer exposed. The Plan of Care orders included skilled nursing (SN) services for performing and teaching wound care to patient and family, observation and assessment of patient impaired nutrition, assess integumentary status and provide skilled assessment and teaching to properly manage diabetic foot care. a) The agency's SN failed to provide wound care as ordered by the physician for Patient #3. Review of the clinical record for Patient #3 revealed the agency treated five different wounds on both legs of the patient. Further review revealed the agency received a new wound care order for all the wounds on 8/31/23. The order read as follows; cleanse site with saline, wound cleanser, gentle soap, pat dry, apply saline moistened promogran collagen, aquacell ag, mextra for drainage, ace bandage to secure. Review of the SN visit notes from 8/31/23 to 10/20/23 revealed wound care was provided on the following visits; 8/31/23, 9/4/23, 9/8/23, 10/3/23, 10/6/23, 10/12/23 and 10/20/23. Review of the wound care provided revealed RN #4 provided wound care for all of the visits. Further review of the wound care revealed RN #4 did not perform wound care as ordered by the physician. RN #4 did not use saline moistened promogran collagen, aquacell AG or mextra for drainage during any of the SN visits. During an interview on 11/16/23 at 11:34 a.m., RN #4 stated the wound care orders that she received came from the wound care clinic. RN #4 also stated that she did not have all the available supplies that the wound care clinic ordered and had to substitute. When asked RN #4 stated she did not remember if she documented contacting the wound care clinic or physician for substitution of the items ordered by the wound care clinic. During an interview on 11/16/23 at 2:22 p.m., the administrator, assistant to the administrator and clinical manager stated they could not find any documentation regarding RN #4 contacting the wound care clinic for substitution of different items for the wound care. 2. Similar findings were found for Patient #1 and #4. 3. During an interview on 11/16/23 at 2:22 p.m., the assistant to the administrator and clinical manager stated the agency had identified issues with SN staff at the agency following physician orders. The assistant to the administrator and clinical manager also confirmed that SN had failed to follow wound care as prescribed by the physician for Patient #1 and #4.